A nurse is reviewing a patient's activities of daily living prior to discharge from total hip replacement. The nurse should identify what activity as posing a potential risk for hip dislocation?
A) Straining during a bowel movement
B) Bending down to put on socks
C) Lifting items above shoulder level
D) Transferring from a sitting to standing position
Ans: B
Feedback:
Bending to put on socks or shoes can cause hip dislocation. None of the other listed actions poses a serious threat to the integrity of the new hip.
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The nurse is performing a focused interview with an elderly client. The client reports the presence of painful sores. The client states, "They wrap around in lines from my back toward my belly."
During the assessment of the client's skin, the nurse discovers the sores are reddened vesicles. The nurse would suspect which of the following conditions? 1. Ecchymoses 2. Herpes zoster 3. Petechiae 4. Purpura
A client with diabetes asks why more than one injection of insulin is required each day. Which is the nurse's best response?
a. "You need to start with multiple injections until you become more proficient at self-injection." b. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns closely enough." c. "A regimen of a single dose of insulin in-jected each day would require that you could eat no more than one meal each day." d. "A single dose of insulin would be too large to be absorbed predictably, so you would be in danger of unexpected insulin shock."
The nurse would recognize the need for additional teaching in a patient after posterior hip replacement when observing which activity?
1. The patient uses an abductor pillow while in bed. 2. The patient uses a regular-height toilet seat. 3. The patient keeps the affected leg and foot turned upright while in bed. 4. The patient keeps the operative leg straight when getting out of bed and uses the arms to push up out of bed.
A client has recently suffered a cerebrovascular accident (CVA, stroke). After providing discharge teaching to the client, which caregiver statement best indicates understanding of discharge teaching for strategies to dealing with dysphagia?
1. "It is necessary to maintain a 90-degree position for at least one hour after meals.". 2. "I should encourage liquids as often as possible.". 3. "Foods like Jell-o and pasta will be easy to swallow.". 4. "I should have the client sit at a 45° angle during all oral (PO) intake.